Philippa Youl

Presentation and detection of invasive melanoma in a high-risk population

BACKGROUND Early detection of melanoma has been encouraged in Queensland for many years, yet little is known about the patterns of detection and the way in which they relate to tumor thickness. OBJECTIVE Our purpose was to describe current patterns of melanoma detection in Queensland. METHODS This was a population-based study, comprising 3772 Queensland residents diagnosed with a histologically confirmed melanoma between 2000 and 2003. RESULTS Almost half (44.0%) of the melanomas were detected by the patients themselves, with physicians detecting one fourth (25.3%) and partners one fifth (18.6%). Melanomas detected by doctors were more likely to be thin (<0.75 mm) than those detected by the patient or other layperson. Melanomas detected during a deliberate skin examination were thinner than those detected incidentally. LIMITATIONS Although a participation rate of 78% was achieved, as in any survey, nonresponse bias cannot be completely excluded, and the ability of the results to be generalized to other geographical areas is unknown. CONCLUSION There are clear differences in the depth distribution of melanoma in terms of method of detection and who detects the lesions that are consistent with, but do not automatically lead to, the conclusion that promoting active methods of detection may be beneficial.

Melanoma in adolescents: A case-control study of risk factors in Queensland, Australia

The incidence of melanoma increases markedly in the second decade of life but almost nothing is known of the causes of melanoma in this age group. We report on the first population‐based case‐control study of risk factors for melanoma in adolescents (15–19 years). Data were collected through personal interviews with cases, controls and parents. A single examiner conducted full‐body nevus counts and blood samples were collected from cases for analysis of the CDKN2A melanoma predisposition gene. A total of 201 (80%) of the 250 adolescents with melanoma diagnosed between 1987 and 1994 and registered with the Queensland Cancer Registry and 205 (79%) of 258 age‐, gender‐ and location‐matched controls who were contacted agreed to participate. The strongest risk factor associated with melanoma in adolescents in a multivariate model was the presence of more than 100 nevi 2 mm or more in diameter (odds ratio [OR] = 46.5, 95% confidence interval [CI] = 11.4–190.8). Other risk factors were red hair (OR = 5.4, 95%CI = 1.0–28.4); blue eyes (OR = 4.5, 95%CI = 1.5‐13.6); inability to tan after prolonged sun exposure (OR = 4.7, 95%CI = 0.9–24.6); heavy facial freckling (OR = 3.2, 95% CI = 0.9–12.3); and family history of melanoma (OR = 4.0, 95%CI = 0.8–18.9). Only 2 of 147 cases tested had germline variants or mutations in CDKN2A. There was no association with sunscreen use overall, however, never/rare use of sunscreen at home under the age of 5 years was associated with increased risk (OR = 2.2, 95%CI = 0.7–7.1). There was no difference between cases and controls in cumulative sun exposure in this high‐exposure environment. Factors indicating genetic susceptibility to melanoma, in particular, the propensity to develop nevi and freckles, red hair, blue eyes, inability to tan and a family history of the disease are the primary determinants of melanoma among adolescents in this high solar radiation environment. Lack of association with reported sun exposure is consistent with the high genetic susceptibility in this group.

Factors related to the presentation of thin and thick nodular melanoma from a population-based cancer registry in Queensland Australia.

Worldwide, the incidence of thick melanoma has not declined, and the nodular melanoma (NM) subtype accounts for nearly 40% of newly diagnosed thick melanoma. To assess differences between patients with thin (≤2.00 mm) and thick (≥2.01 mm) nodular melanoma, the authors evaluated factors such as demographics, melanoma detection patterns, tumor visibility, and physician screening for NM alone and compared clinical presentation and anatomic location of NM with superficial spreading melanoma (SSM).

Time trends and latitudinal differences in melanoma thickness distribution in Australia, 1990–2006

This study investigated time trends and latitude differentials in the thickness distributions of invasive melanomas diagnosed in Australia between 1990 and 2006 using data from population‐based cancer registries. Trends in incidence rates were calculated by sex, age group, thickness, year at diagnosis and latitude. For thin (<1.00mm) melanomas the increase was very pronounced during the early 1990s (1990–1996, annual percentage change and 95% confidence interval: males +5.6(+3.5,+7.7); females +4.1(+1.7,+6.5), but then incidence rates became stable among both males (+0.6(−0.1,+1.4)) and females (−0.0(−0.9,+0.9)) of all ages between 1996 and 2006. In contrast, incidence of thick (>4.00 mm) melanomas continued to increase over the entire period (males +2.6(+1.9,+3.4); females +1.6(+0.6,+2.6)). Recent reductions in the incidence of thin melanomas were observed among young (<50 years) males and females, contrasted by an increase in thin melanomas among older people, and increases in thick melanomas among most age groups for males and elderly (75+) females. A strong latitude gradient in incidence rates was observed, with rates being highest in northern, more tropical areas and lowest in the most southern regions. However, the magnitude of the increase in thick melanomas was most pronounced in southern parts of Australia. The observed trends in thin melanomas can most likely be attributed to the impact of early detection and skin awareness campaigns. However, these efforts have not impacted on the continued increase in the incidence of thick melanomas, although some increase may be due to earlier detection of metastasising melanomas. This highlights the need for continued vigilance in early detection processes.

Prevalence of whole-body skin self-examination in a population at high risk for skin cancer (Australia).

AbstractObjective: Whole-body skin self-examination (SSE) with presentation of suspicious lesions to a physician may improve early detection of melanoma. The aim of this study was to establish the prevalence and determinants of SSE in a high-risk population in preparation for a community-based randomised controlled trial of screening for melanoma. Methods: A telephone survey reached 3110 residents older than 30 years (overall response rate of 66.9%) randomly selected from 18 regional communities in Queensland, Australia. Results: Overall, 804 (25.9%) participants reported whole-body SSE within the past 12 months and 1055 (33.9%) within the past three years. Whole-body SSE was associated in multivariate logistic regression analysis with younger age ( <50 years); higher education; having received either a whole-body skin examination, recommendation or instruction on SSE by a primary care physician; giving skin checks a high priority; concern about skin cancer and a personal history of skin cancer. Conclusion: Overall, the prevalence of SSE in the present study is among the highest yet observed in Australia, with about one-third of the adult population reporting whole-body SSE in the past threeyears. People over 50 years, who are at relatively higher risk for skin cancer, currently perform SSE less frequently than younger people.

The Impact of Body Mass Index and Physical Activity on Mortality among Patients with Colorectal Cancer in Queensland, Australia

Background: Few studies have investigated the impact of body mass index (BMI) and physical activity (PA) on mortality among colorectal cancer (CRC) patients and the results are inconsistent. We aimed to examine the impact of these lifestyle factors on all-cause and disease-specific mortality. Methods: Population-based longitudinal study followed 1,825 patients diagnosed with stages I to III primary CRC during 2003 to 2004 in Queensland, Australia for 5 years. Sociodemographics and clinical characteristics were obtained via questionnaires and medical records. Results: Participants with some level of PA following diagnosis had 25% to 28% lower risk of all-cause mortality within 5 years of diagnosis than sedentary participants [insufficiently active: HR = 0.72, 95% CI = 0.57–0.91; sufficiently active: HR = 0.75 (0.60–0.94)]; however, the differential for CRC-specific mortality was not significant. Increases in PA from five to 12 months postdiagnosis was associated with reduced CRC-specific mortality by 32% to 36% (increase ≤ 2 hour per week: HR = 0.68 (0.48–0.97); increase > 2 hour per week: HR = 0.64 (0.44–0.93) and 31% for all-cause mortality (increase >2 hour per week: HR = 0.69 (0.50–0.94). Compared with participants with healthy BMI, significant higher mortality risk was observed in underweight patients (all-cause: HR = 2.29 (1.47–3.59); CRC: HR = 1.74 (1.00–3.04), although lower risk in overweight (all-cause: HR = 0.75 (0.61–0.94); CRC: HR = 0.75 (0.59–0.97) and no difference in obese. Excessive weight loss was associated with increased mortality risk by three-fold but no difference in those who gained weight. Conclusions: Protective effects of being physically active and increasing that activity underlines the importance of interventions to increase activity levels among people being diagnosed with CRC. Impact: Increased mortality risks associated with being underweight or having weight loss over time is an important indicator for which clinicians, patients, and support personnel can monitor. Cancer Epidemiol Biomarkers Prev; 20(7); 1410–20. ©2011 AACR.

Incidence and Survival for Merkel Cell Carcinoma in Queensland, Australia, 1993-2010

IMPORTANCE Merkel cell carcinoma (MCC) is an uncommon but highly invasive form of skin cancer. The mechanisms that cause MCC are yet to be fully determined. OBJECTIVES To compare the incidence and survival rates of MCC in Queensland, Australia, known to be a high-risk area, with MCC incidence and survival elsewhere in the world. We also analyzed incidence trends and differences in survival by key demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of population-based administrative data for MCC collected by the Queensland Cancer Registry and supplemented with detailed histopathologic data. Deidentified records were obtained of all Queensland residents diagnosed as having MCC during the period from 1993 to 2010. A subsample of histopathologic records were reviewed by a senior dermatopathologist to determine the potential for misclassification. A total of 879 eligible cases of MCC were included in the study. MAIN OUTCOMES AND MEASURES Incidence rates were directly age standardized to the 2000 United States Standard Population. Trends were examined using Joinpoint software with results expressed in terms of the annual percentage change. The period method was used to calculate 5-year relative survival, and adjusted hazard ratios were obtained from multivariate Poisson models. RESULTS There were 340 cases of MCC diagnosed in Queensland between 2006 and 2010, corresponding to an incidence rate of 1.6 per 100,000 population. Men (2.5 per 100,000) had higher incidence than women (0.9 per 100,000), and rates peaked at 20.7 per 100,000 for persons 80 years or older. The overall incidence of MCC increased by an average of 2.6% per year from 1993 onwards. Relative survival was 41% after 5 years, with significantly better survival found for those younger than 70 years at diagnosis (56%-60%), those with tumors on the face or ears (51%), and those with stage I lesions (49%). CONCLUSIONS AND RELEVANCE Incidence rates for MCC in Queensland are at least double those of any that have been previously published elsewhere in the world. It is likely that Queenslands combination of a predominantly white population, outdoor lifestyle, and exposure to sunlight has played a role in this unwanted result. Interventions are required to increase awareness of MCC among clinicians and the public.

Increase in Skin Cancer Screening During a Community-Based Randomized Intervention Trial

Survival from cutaneous melanoma is mainly dependent on the thickness of the lesion at diagnosis. Skin screening may increase detection of thin lesions and hence improve survival. Within a community‐based randomized controlled trial of a population screening program for melanoma in Queensland, Australia, 9 communities were randomly assigned to the 3‐year intervention and 9 communities to the control group. Skin screening prevalence was monitored by cross‐sectional surveys at baseline, 1, 2 and 3 years into the intervention and 2 years later. At baseline, prevalence of whole‐body clinical skin examination was similar in intervention and control communities. In intervention communities, the prevalence of whole‐body skin examinations increased to 29.2%, an absolute difference of 18% from baseline, with a peak of 34.8% 2 years after baseline, and began to decline again at the end of the intervention period. The largest increases were seen in men and women ≥50 years. Uptake of screening did not differ according to melanoma risk factors; however, the decline in screening was less in participants who reported a number of melanoma risk factors. The prevalence of skin self‐examination remained stable during the intervention program. No changes were observed in the control communities. These results indicate that the intervention program significantly increased the prevalence of whole‐body clinical skin examinations in intervention communities. Once the intervention program ceased, and particularly after skin clinics ceased, levels of skin screening began to decline. The provision of specialized skin screening clinics may be needed to achieve sufficient screening rates should population based screening for skin cancer be considered.

Association between melanoma thickness, clinical skin examination and socioeconomic status: Results of a large population‐based study

Survival from melanoma is inversely related to tumour thickness and is less favorable for those in lower socioeconomic (SES) strata. Reasons for this are unclear but may relate to a lower prevalence of skin screening. Our aim was to examine the association between melanoma thickness, individual‐level SES and clinical skin examination (CSE) using a population‐based case‐control study. Cases were Queensland (Australia) residents aged 20–75 years with a histologically confirmed first primary invasive cutaneous melanoma diagnosed between January 2000 and December 2003. Telephone interviews were completed by 3,762 cases (77.7%) and 3,824 (50.4%) controls. Thickness was dichotomized to thin (≤2 mm) and thick (>2 mm). Compared with controls, the risk of thick melanoma was significantly increased among men [relative risk ratio (RRR) = 1.56, 95% CI = 1.22–2.00], older participants (RRR = 1.76, 95% CI = 1.10–2.82), those educated to primary level (RRR = 1.70, 95% CI = 1.08–2.66), not married/living as married (RRR = 1.47, 95% CI = 1.15–1.88), retired (RRR = 1.39, 95% CI = 1.01–1.94) and not having a CSE in past 3 years (RRR = 1.45, 95% CI = 1.12–1.86). There was a significant trend to increasing prevalence of CSE with higher education (p < 0.01) and the benefit of CSE in reducing the risk of thick melanoma was most pronounced among that subgroup. There were no significant associations between cases with thin melanoma and controls. Melanoma thickness at presentation is significantly associated with educational level, other measures of SES and absence of CSE. Public health education efforts should focus on identifying new avenues that specifically target those subgroups of the population who are at increased risk of being diagnosed with thick melanoma.

Factors Associated With the Number of Lesions Excised for Each Skin Cancer: A Study of Primary Care Physicians in Queensland, Australia

OBJECTIVE To assess physician, patient, and skin lesion characteristics that affect the number of benign skin lesions excised by primary care physicians for each skin cancer. DESIGN Prospective study collecting clinical, patient, and histopathologic details of excisions or biopsies of skin lesions by random samples of primary care physicians. SETTING Southeast Queensland involving traditional family medicine physicians (n = 104; response rate, 53.9%) and family medicine physicians working in 27 primary care skin cancer clinics (n = 50; response rate, 75.0%). PARTICIPANTS Of 28 755 skin examinations recorded during the study, 11 403 skin lesions were excised or biopsied; 97.5% of the excised lesions had clinical and histologic diagnoses recorded. MAIN OUTCOME MEASURES Number of lesions needed to excise or biopsy (NNE) for 1 melanoma (pigmented lesions only) and NNE for 1 nonmelanoma skin cancer (nonpigmented lesions only). RESULTS The NNE for nonpigmented lesions (n = 8139) was 1.5 (95% confidence interval, 1.4-1.6) and for pigmented lesions (n = 2977) was 19.6 (16.2-22.9). The NNE estimates were up to 8 times lower if the physician thought the lesion was likely to be malignant and up to 2.5 times higher if there was strong patient pressure to excise. The NNE estimates varied by other physician-, patient-, and lesion-related variables. CONCLUSIONS Clinical impressions of excised skin lesions were strongly associated with NNE estimates. By focusing on pigmented skin lesions and by addressing the physician- and patient-specific factors identified, the effectiveness of future training for primary care physicians in the clinical management of skin cancer could be improved.